If you’ve been half awake in recent days, you might have heard of a new study showing that “babies are seven times more likely to die during home births”.
It’s worth having a close look at what the study actually found (the full article is available here in the Medical Journal of Australia), and also considering some of the broader context that has been sadly lacking from most of the coverage I’ve seen and heard.
Please bear with me — I’m about to hit you with a stack of figures — but it is worth taking the time to examine them in some depth. You may end up with a different impression from what the headlines have been saying.
The researchers compared the outcomes for 287,192 planned hospital births that took place in SA between 1991 and 2006 with those of 1141 planned home births. Note that this latter group was defined as any birth intended to occur at home at the time of antenatal booking, but about 30% actually ended up occurring in hospital (the researchers were unable to say how many women went to hospital before or during labour).
During those 16 years, there were nine perinatal deaths in the planned home birth group (seven of which actually occurred in babies born in hospital), and 2440 deaths in the group with a planned hospital birth. Two deaths occurred among the 792 infants born at home, one of whom had congenital abnormalities.
Once the babies with birth defects were excluded from the calculations, the perinatal mortality rate for planned home births was 4.5 per 1000 births versus 6.7 per 1000 for hospitals — the difference was not statistically significant.
As you might expect, the rates of caesarean sections and other interventions were significantly lower in the home-birth group. Nine per cent of women who’d planned a home birth ended up having a caesarean, versus 27% of the hospital birth group.
The home-birth babies were more likely to die during labour and delivery (intrapartum death) but the numbers were so small, there is a wide range of uncertainty surrounding the estimates of how their risk compared with the hospital group’s. (And remember that the overall perinatal death rate for the two groups was the same).
Where the media generally reported home-birth babies being seven times more likely to die during delivery, the estimate ranges from them being anywhere between 1.5 and 36 times more likely to have this happen. Such a wide-ranging estimate means, as the authors themselves state, “small numbers with large confidence intervals limit interpretation of these data”.
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To go back to the actual numbers, over the period of the study, there were 247 intrapartum deaths among the planned hospital births and two among the planned home births (one of which occurred in a baby who ended up being born in hospital).
A similar caution surrounds the widely reported finding that home-birth babies were 27 times more likely to die from lack of oxygen during delivery. Again, this finding had wide confidence intervals, with the estimate ranging from eight to 89 times greater — clearly, another one to take with caution.
Looking at the raw data, 87 babies in the hospital group died due to lack of oxygen during the delivery, compared with three in the planned home-birth group (two of whom ended up being born in hospital).
The researchers note that during the 16 years of the study in relation to the home births, “there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth or timing of transfer to hospital might have made a difference to the outcome.”
It is also worth noting that one of these three deaths occurred in a twin. The reason the parents persisted in a home birth despite being advised against it was that they “had had unsatisfactory hospital experiences during previous pregnancies”.
The researchers also said “it is reassuring that the rate of postpartum haemorrhage, which had been of concern in earlier Australian studies, was not higher for planned home births than planned hospital births”.
In other words, there is quite a lot of good news for home-birth advocates in this study. Given the health system’s historic lack of support for those who choose home birth and their carers, you could argue that one of the main inferences from the study is that it is quite amazing that more adverse outcomes were not reported.
Another inference I take is that rather than damming home birth, the health system and health professionals should be doing more to improve support and integration of care.
So why did we end up with headlines emphasising the shock horror out of all context?
One factor has to be the MJA’s decision to have Dr Andrew Pesce, an obstetrician and gynaecologist who is the president of the AMA, which is opposed to home birth in Australia, write the editorial accompanying the study.
Given the intense politicking that has surrounded home-birth policy in the context of maternity services reform, it might have been more useful to have an editorialist from outside the political fray, or even the country.
The editorial gave the AMA another platform for directing the media coverage, and its press release accompanying the journal also was geared towards producing the headlines we got.
I’m not surprised that the Australian College of Midwives has sent its take on the whole sorry saga to Media Watch, where it deserves some serious attention. One home-birth advocate told me that of the several journalists who interviewed her, none had actually read the study and all just swallowed the AMA line.
Meanwhile, it seems more pertinent than ever to borrow the final words of the study’s authors:
Although it is not anticipated that large numbers of women will opt for home birth, women’s autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law.
Respecting their choices and achieving the best outcome for all concerned is likely to remain a challenge that will require more light and less heat than it has received thus far.
What we’ve learnt in recent days is that we can’t rely on the media — or medical organisations — to contribute much light to this debate.